Op. Dr. Orhan Coşkun
Known medically as sclerotherapy and colloquially as foam or needle treatment for varicose veins, this treatment method has become widely popular in recent years. The most significant reasons for its popularity are that it is a relatively easy method that can be performed even in outpatient settings, applicable to all types of varicose veins, does not require restrictions in the patient’s social life, and is a comfortable procedure.
However, it’s important to note that due to its perceived simplicity, it has also been adopted by those who are not experts in the field. Is it really easy to apply? Yes, administering this treatment is easy, but doing it correctly is challenging. Therefore, one of the most significant complications is patient dissatisfaction. When applied in the right hands and with the correct method, achieving high patient satisfaction rates, such as 95%, is possible.
The fundamental principle in treating varicose veins is based on the logic of eliminating the diseased structure that has lost its function and now causes more harm than good. In the past, varicose veins were removed from their locations through surgery. However, modern treatment trends focus on canceling the diseased vein in its place and allowing the body’s healing mechanism to eliminate it. Some methods use heat effects for this vein cancellation (such as laser, radiofrequency), while foam sclerotherapy induces damage to the inner surface of the vein with chemical effects, ensuring the cancellation of the diseased vein. Over time, the body absorbs and eliminates it. The most commonly used drug for this purpose is a compound called polidocanol. This drug ensures closure of the diseased vein by causing damage to its inner lining, and it does not harm the body, being eliminated within 8 hours.
MECHANISM OF ACTION
The commercial name of the drug used in the treatment is Aethoxysklerol, and its active ingredient is Lauromacrogol 400 (polidocanol). The drug has a concentration-dependent effect on the endothelium (inner lining) of blood vessels. Lauromacrogol 400 (polidocanol) functions as a detergent. It interacts with the surface of endothelial cells, disrupting the cells by dissolving essential molecules from the cell surface.
Therefore, when injected into the vein, Lauromacrogol 400 (polidocanol) destroys the walls of the affected varicose veins, thereby permanently blocking them. As mentioned above, the initial effect of the drug causing endothelial damage leads to the gathering of platelets (blood cell fragments that form clots) in the damaged area and their adhesion to the varicose vein wall. Subsequently, an intense network of platelets, cellular debris, and fibrin block the vein. In a later stage, the closed vein is replaced by fibrous tissue (scar tissue).
This scar tissue and clots gradually break down and are absorbed by the body, eliminating the varicose vein.
As a result, sclerotherapy corresponds to the surgical removal of varicose veins.
To reduce post-sclerotherapy clot formation and prevent the reopening of the vein, gradient compression stockings (varicose stockings) or bandages are recommended.
Aethoxysklerol is available in concentrations of 0.5%, 1%, 2%, and 3%. The dose is selected based on the diameter and extent of the varicose vein, and it is essential not to exceed the calculated dose based on the patient’s weight at once.
When used in foam form, it is crucial not to exceed a certain dose of air to be administered. Of course, the selection of this dose, the frequency, and the method of application are also crucial, considering the patient’s condition and existing diseases.
FOAM SCLEROTHERAPY APPLICATION METHODS
1- Classic Liquid Sclerotherapy: Sclerotherapy performed by injecting liquid medication into the varicose vein using thin needles. Suitable for veins with a diameter of 1 mm.
2- Micro-Sclerotherapy: Treatment performed with very fine needles and the practitioner using magnifying glasses. Mostly liquid medication is used. Applied for capillaries with a diameter below 1 mm.
3- Foam Sclerotherapy: In this method, the medication is mixed with air to form foam using a three-way tap and two injectors. The goal here is to expand the volume of the drug, thus increasing the likelihood of contact with the inner vascular wall. Applied to veins larger than 1 mm (1-5 mm).
4- Ultrasound-Guided Foam Sclerotherapy: Foam treatment performed under ultrasound guidance for the treatment of valve insufficiency and dilations in both large and small saphenous veins, which are the main veins. A catheter is inserted into the diseased vein under ultrasound guidance, and foam is injected into the vein from there, similar to attaching an IV. Afterward, elastic bandages and varicose stockings are worn. While in other methods, using varicose stockings for 2 weeks after the application is sufficient, after this method, using varicose stockings for an additional 6 weeks is essential to reduce the risk of recurrence.
All sclerotherapy methods are painless, do not require hospitalization or anesthesia, and the patient can immediately return to their normal activities after the procedure.
HOW IS SCLEROTHERAPY (FOAM TREATMENT) APPLIED?
There is no need for hospitalization for the treatment; it can be performed in well-equipped outpatient clinics. Basic materials required for this procedure include single-use syringes, a three-way tap, needles of various sizes, magnifying glasses, gloves, a veinlight device to visualize subcutaneous varicose veins that are not visible from the outside, Doppler ultrasonography for the treatment of deeper veins, a movable examination table or a special apparatus for foot elevation, gauze pads, sterile liquids, compression bandages, and compression support materials, along with an assistant who will provide the necessary support.
After the patient lies on the examination table, subcutaneous varicose veins are evaluated using veinlight, and treatment areas are marked. Starting from the largest varicose veins, the treatment progresses towards smaller ones. If there is insufficient valve function causing the varicose veins, foam sclerotherapy is first performed under ultrasound guidance, followed by treatment of other varicose veins.
After the foam or liquid injection, a compression support material is placed over the vein, and an elastic bandage is applied. The patient is informed about the duration the bandage needs to stay in place, depending on the diameter of the vein.
The patient is also provided with varicose stockings to wear during the treatment, and instructions on their use are given.
During foam application, the patient can observe the foam entering the varicose vein, pushing the blood, and making the varicose vein disappear. However, this does not mean the vein magically disappears at that moment. The medication touching the inner vascular wall initiates the effects mentioned earlier and starts a healing process, leading to the closure and disappearance of the vein. The completion of this healing process varies from person to person, ranging from 15 days to 3 months, and sometimes longer.
After the treatment, there may be bruising and hardness at the application site, which will gradually disappear. Creams and gels may be prescribed to the patient for faster recovery of these effects.
It is necessary to consume plenty of fluids and engage in at least 15-20 minutes of walking after the treatment.
Avoid heavy exercise and extreme heat, such as saunas, for three days. Patients planning to travel should consult with their doctor to take precautions based on the length of their journey.
WHO IS NOT ELIGIBLE FOR FOAM TREATMENT?
- Individuals allergic to the medication used for treatment
- Advanced arterial disease
- Individuals who are bedridden and cannot move
- Diabetic patients (depending on severity)
- Advanced obesity
- Pregnant women
- Those who have experienced deep vein thrombosis
- Patients with a high tendency for blood clotting
- Individuals who cannot use varicose stockings or bandages
IS FOAM TREATMENT PERFORMED DURING THE BREASTFEEDING PERIOD?
There is no study conducted on this matter in humans; however, there are two approaches. The first approach does not recommend performing the treatment during this period due to the possibility of postponing the application and the lack of sufficient evidence. On the other hand, those following the second approach carefully perform the treatment by paying attention to the 8-hour periods in which the drug is eliminated from the body and using the breast pumping method. I personally follow the first approach, but I have also treated breastfeeding mothers. In such cases, it may be advisable to temporarily pause breastfeeding for 2-3 days based on the recommendation of the manufacturer. For instance, one of my patients had passed the first year of breastfeeding, and after the treatment sessions, she could abstain from breastfeeding for a while.
CAN FOAM TREATMENT BE APPLIED TO HAND VEINS?
Yes, foam sclerotherapy or liquid sclerotherapy treatment can be applied to the dilated veins on the hands. These veins can be brought to a more reasonable appearance in 2-3 sessions.
In individuals who perform heavy tasks and exercises with their hands, or sometimes due to genetic reasons, these veins may dilate, affecting the aesthetic appearance of the hands. Similar situations may arise in the aging period due to the loss of subcutaneous fat and tissue.
One crucial point to consider in this treatment is not to completely eliminate all veins on the hands. This is because these veins can be utilized for treatment purposes during the disease period.
FOAM TREATMENT FOR HEMANGIOMA
Foam sclerotherapy is one of the significant treatments for childhood hemangiomas. Especially in cavernous hemangiomas that affect the skin and subcutaneous tissue, successful results are achieved with foam treatment.
Similar to varicose veins, the drug that comes into contact with the inner surface of these diseased vascular clusters damages them, ensuring their drying and resolution.
WHAT ARE THE SIDE EFFECTS OF FOAM TREATMENT?
No treatment is without complications, and the experience of the physician only reduces the frequency and severity of complications. What the patient needs to do is to consult the right physician, someone specialized in the field, and trust them.
Complications that may be encountered with sclerotherapy treatment are as follows:
1- Allergic reactions
Allergic reactions to the used medication may develop. In such cases, the treatment cannot continue, and alternative methods should be considered.
2- Urticaria
Hives are itchy and red lesions in the form of bubbles seen at the application site. They resolve spontaneously (within 24 hours at the latest), and if they cause significant discomfort, some creams can be used.
3- Excessive color change (darkened scar, hyperpigmentation)
It occurs when the coloring pigment from dead blood cells in the clot comes to the skin. It heals within 60% in 6 months and 90% in 1 year. It may be permanent in 1-10% of patients.
Excessive and direct exposure of the treated area to sunlight, the use of certain medications (minocycline, iron storage drugs), having dark skin color increases the likelihood of occurrence. Whitening creams, IPL laser can be used in treatment.
4- Intravascular clot formation
These clots must be removed with a needle; otherwise, they may cause the coloring substance to come to the skin, leading to darkening.
5- Formation of New Vessels: Telangiectatic Matting
It involves the presence of numerous reddish vessels with a diameter of 0.1-0.2 mm in the previously treated vessel area, and the cause is unknown. It can be seen in 15-25% of patients.
In case of development, it should be checked whether there is venous insufficiency in the patient, and whether they use birth control pills. Birth control pills should be discontinued one month before treatment and resumed two months after the end of treatment. Obese patients should be encouraged to lose weight.
There is no need to rush for matting treatment; the patient should be informed that it can heal spontaneously, and if it does not improve, it should be treated. IPL laser can also be used.
6- Skin Necrosis:
It is a skin injury that develops due to the occlusion of the arterial component of the vascular bed. It can occur due to the effect of the drug that has escaped outside the vessel and heals between 1-3 months.
7- Superficial Venous Thrombosis:
Also known as thrombophlebitis. It is the hardening, redness, and tenderness of the vein with the settling of a clot in the superficial vein. This is important in terms of the possibility of the patient having DVT at the same time or the risk of developing DVT later.
It can heal spontaneously. To speed up the healing, warm compresses, anti-inflammatory drugs, and blood thinning injections can be used.
8- Deep Vein Thrombosis (DVT):
It can occur as a result of excessive injection of the drug, leading to the passage of the drug into the deep veins. It manifests itself with severe pain in the leg, excessive expansion and hardening of the calf and thigh. Application of compression after treatment, ankle movements that work the calf muscles, walks immediately after treatment, and drinking plenty of fluids are recommendations to prevent this complication.
9- Sensory Nerve Damage:
Damage to sensory nerves accompanying superficial veins may occur with sclerotherapy. Perceived as mild numbness and numbness in that area. This condition is temporary and heals spontaneously. Since these nerves are not related to movement, they do not cause more damage.
10- Neurological Complications:
Symptoms such as headache, blurred vision, dizziness, and temporary loss of vision may occur. Most neurological findings have been found to be related to the patient’s existing congenital heart disease.
11- Injection into Arteries
12- Patient dissatisfaction
